Based on record reviews, and interviews, the facility failed to ensure that two Residents (#11 and #56) of five applicable residents, out of a total sample of 19 residents were free from unnecessary psychotropic medications. Specifically:For Resident #11, the facility failed to ensure a Physican order for PRN antipsychotic medications was limited to 14 days.For Resident #56, the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted related to antidepressant medication use or provide supporting evidence that a GDR attempt was contraindicated. Findings include: 1. Review of the facility policy titled Antipsychotic Medication Use, revised July 2022, indicated the following: -PRN (as needed) orders for antipsychotic medications will not be renewed beyond 14 days unless the heath care practitioner has evaluated the resident for appropriateness of that medication and documented the rationale for continued use. -The duration of the PRN order will be indicated in the order. Resident #11 was admitted to the facility in March 2025, with diagnoses including Vascular Dementia with Mood Disturbances. Review of Resident #11's July 2025 Physician's orders included the following: -Haloperidol Lactate (Haldol - antipsychotic medication) 2 milligram/milliliter (ml), give 0.5 ml by mouth every 6 hours as needed (PRN) for agitation, effective 5/14/25. -Further review of the Physician's orders failed to indicate a limit or duration of use for the PRN Haldol medication. Review of Resident #11's Medication Administration Records (MAR's) for May 2025 through July 2025 indicated Resident #11 was administered the PRN dose of Haldol on the following days: -5/21/25 -7/18/25 Review of Resident #11's Medical Record failed to indicate limited use of PRN Haldol medication to 14 days as required. During an interview on 7/28/25 at 3:52 P.M., the Director of Nursing (DON) said that Resident #11 did not have the required 14-day limit included in the antipsychotic PRN order for his/her Haloperidol Lactate (Haldol). The DON said that the PRN antipsychotic medication prescribed to Resident #11 should have had a 14-day duration, unless otherwise specified by a Provider. The DON said Resident #11 did not have supporting documentation by a Provider for the extended use of the Haloperidol Lactate (Haldol). 2. Review of the facility policy titled Psychotropic Medication Use, dated July 2022, included but was not limited to the following: -Residents on Psychotropic medications receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these medications. Resident #56 was admitted to the facility in May 2024 with diagnoses including Depression. Review of Resident #56's July 2025 Physician's orders included the following: -Mirtazapine (antidepressant medication) 30 milligrams (mg) by mouth two times a day, initiated 5/30/24. -Wellbutrin (antidepressant medication) 150 mg by mouth once a day in the morning, initiated 5/31/24. Review of Resident #56's Minimum Data Set (MDS) Assessment, dated 6/10/25, indicated: -The Resident was taking an Antidepressant medication. -No GDR had been attempted. -No contraindications for GDR had been documented by a Physician. Further review of Resident #56's medical record failed to indicate any evidence that a GDR of the Psychotropic medication had been attempted or that a GDR was contraindicated when the Resident had received psychotropic medications at the same dosage for over one year. During an interview on 7/29/25 at 10:30 A.M., the Director of Nursing (DON) said that Resident #56 was receiving psychotropic medications, and no GDR had been attempted. The DON said that she was unable to provide evidence that GDR of the psychotropic medications were attempted or contraindicated. The DON said a GDR should be attempted at least quarterly for Residents receiving psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#56) out of a total sample of 19 residents.Specifically, for Resident #56, the facility staff failed to follow the Physician order's relative to the Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled Catheterization Foley, dated April 2018, indicated:-Indwelling urinary catheters are used only when there is valid medical justification.-the Foley catheter will be changed only when needed, unless otherwise specified by the Physician, Nurse Practitioner (NP) or Physician Assistant (PA).-Foley catheters should be changed when:>urinary tract infection is suspected>clogged or unable to irrigate>displaced (balloon [retention balloon - a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body] suspected to be in urethra)>resident discomfort>MD (Medical Doctor/Physician) order Resident #56 was admitted to the facility in May 2024 with diagnoses including urinary retention and obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #56:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. -had an indwelling urinary catheter-was dependent on staff for activities of daily living (ADL's - basic skills such as bathing, dressing, eating, etc.). Review of Resident #56's July 2025 Physician orders indicated:-Foley catheter 16 French [Fr - size measurement]/10 milliliter (ml) balloon, change PRN (as needed) for signs and symptoms of infection, one time a day, starting on the 10th every month, related to retention of urine, initiated 4/10/25. On 7/25/25 at 10:31 A.M., the surveyor and Nurse #5 observed Resident #56's Foley catheter and Nurse #5 said the size of the Foley catheter was 14 Fr, and the balloon size was faded and unreadable. During an interview on 7/25/25 at 10:35 A.M., the surveyor and Nurse #5 reviewed Resident #56's Foley catheter orders and Nurse #5 said the Resident's Foley catheter order was for size 16 Fr and 10 ml balloon. The surveyor and Nurse #5 then reviewed the Resident's Treatment Administration Record (TAR). Nurse #5 said the TAR indicated that Resident #56's Foley catheter had been changed on 7/10/25 and signed off by a Nurse as size 16 French and 10 ml balloon but the Foley catheter was not changed.During an interview on 7/25/25 at 10:39 A.M., the Director of Nursing (DON) said Resident #56's Foley catheter did not reflect the current Physician's orders and that the Resident's Foley catheter had not been changed as ordered. Please Refer to F842

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to provide adequate nutritional care and services for one Resident (#39), out of a total sample of 19 residents. Specifically, the facility failed to appropriately address a significant weight loss when Resident #39 was identified as having a greater than 5 percent (%) weight loss in one month and no re-weight was completed as required. Findings include: Review of the facility policy titled .Nursing Policy and Procedure Manual: Nutritional Services, last revised May 2024, indicated the following:-The facility will perform the following best practice guidelines to manage risk of unplanned weight change and ensure the nutritional needs are met for all residents.-Residents are weighed a minimum of monthly, by the 7th day of each month with more frequent weights obtained as ordered or deemed necessary.-Residents are weighed in a consistent manner, using the same scale, consistent time of day, and consistent clothing/devices at time of weight.-Weights are verified and documented in the medical record as they are obtained.-Check the previous monthly weight for any significant weight change. If there is a significant weight change of +/- 5% (percent) in 30 days, +/- 7.5% in 90 days or +/- 10% in 180 days, the Dietician will review nutritional needs and add or discontinue interventions as needed.-Nursing will re-weigh any resident with a +/- 5 pounds in a month within 24 hours. Resident #39 was admitted to the facility in June 2024 with diagnoses including Unspecified Nutritional Deficiency, Unspecified Severe Protein-Calorie Malnutrition, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #39 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of the active Physician Orders, dated 7/29/25, indicated the following:-Regular Diet, Mechanical Soft texture, thin consistency, initiated 6/13/24. Review of Resident #39's medical record indicated the following weights:-5/1/25: 140 pounds (lbs.)-6/2/25: 138 lbs. (down 2 lbs. from 5/1/25)-7/6/25: 122 lbs. (down 16 lbs. from 6/2/25, and down 18 lbs. since 5/1/25) Further review of the weight record indicated Resident #39 experienced a sixteen-pound weight loss in thirty days duration from 6/2/25 to 7/6/25. Review of a Nurse Practitioner (NP) Progress Note dated 7/7/25, indicated:-Abnormal weight loss - Monthly weights reviewed, significant weight loss noted 138 pounds to 122 pounds.-Weight is likely inaccurate and should be attempted again. -PO (by mouth) intake is variable but typically around 50% of meals.-Patient is followed by the Dietician to ensure nutritional needs are being met. Review of Resident #39's Dietician Progress Note dated 7/9/25, indicated:-Weight Warning: weight change of 16 pounds, 11.6% weight loss in the last thirty days.-Recommend reweigh, this is a significant change from last month. Further review of the Resident's medical record failed to indicate that any further weight measurements were obtained for Resident #39 after the recorded weight of 122 lbs. on 7/6/25. During an interview on 7/28/25 at 1:24 P.M., with Certified Nurse Aide (CNA) #2, Nurse #3 and Nurse #2, CNA #2 said that everyone on the unit helps to obtain weights for the residents at the beginning of every month. CNA #2 said that the staff know the residents very well and if a weight measurement for any resident doesn't seem accurate, then staff reweigh the resident. Nurse #3 said that at the beginning of each month the Director of Nursing (DON) provides the nursing unit with a list of residents who require weight measurements. Nurse #3 said that all monthly weights are required to be completed by the sixth day of the month, and the DON will come to the nursing unit and let staff know if a resident requires a re-weight to be obtained. Nurse #3 further said that all weight measurements are documented in the electronic health record. Nurse #2 said that the Assistant Director of Nurses (ADON) or the DON will tell staff if a resident needs to be reweighed and all weights are documented in the electronic health record. During an interview on 7/28/25 at 2:50 P.M., the DON said at the beginning of every month she provides a weight sheet to each nursing unit indicating which residents require weight measurements for the month. The DON said that the weight sheet contained previous weight measurements for all residents so that staff can compare resident weights from month to month and obtain a re-weight for any resident who experienced a significant weight change. The DON said if a resident experienced significant weight change, then the resident should be re-weighed within a day or two and weight measurements documented in the electronic medical record (EMR). The DON said that Resident #39 experienced a significant weight change on 7/6/25 and staff should have re-weighed the Resident to confirm the significant weight change. The DON further said that she could not provide any evidence that Resident #39 had been re-weighed, but the Resident should have been re-weighed.During a telephone interview on 7/29/25 at 10:07 A.M., the Dietician said that that she works in the facility one day per week and monitors resident weights by using the weekly weight report generated by the electronic health record. The Dietician said that all residents are weighed by the sixth day of the month. The Dietician further said that she will notify the DON, the Provider or the nursing staff if a resident requires a re-weigh and expected staff to obtain a re-weight measurement within the same week. The Dietician also said that she was aware that Resident #39 had experienced significant weight change, but she did not recall asking staff or the DON to re-weigh the Resident. The Dietician said that Resident #39 should have been re-weighed to confirm the significant weight change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#29), out of a total sample of 19 residents. Specifically, for Resident #29, the facility failed to ensure that Physician orders for oxygen use were in place when the Resident was being administered oxygen. Findings include: Review of the facility policy titled Oxygen Administration - Reservoir or Pendant Style Nasal Cannula/Oxymizer, adopted November 2017, indicated:-Policy: To deliver low flow oxygen rates and concentration, per the Physician's order via oxygen conserving devices that serve to reduce oxygen usage and nasal irritation. Resident #29 was admitted to the facility in June 2025 with diagnoses including Chronic Kidney Disease (CKD), Obstructive Sleep Apnea (OSA), Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #29 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. On 7/28/25 at 8:00 A.M., the surveyor observed Resident #29 seated on the edge of his/her bed with a nasal cannula in place connected to an oxygen concentrator set at 4 LPM (liters per minute) oxygen flow rate. During an interview at the time, Resident #29 said he/she always wears oxygen set at 4 LPM. Review of Resident #29's current Physician orders failed to indicate any Physician orders in place for the use of oxygen. During an interview on 7/28/25 at 10:42 A.M., Nurse #2 said that Resident #29 was receiving oxygen therapy at 4 LPM via nasal cannula. Nurse #2 said she thought Resident #29 should be administered oxygen therapy set at 4 LPM because the Resident had respiratory disease and was admitted to the facility with the oxygen set at 4 LPM in place. The surveyor and Nurse #2 reviewed Resident #29's Physician orders and Nurse #2 said that there were no Physician orders in place for the Resident's oxygen therapy but there should have been Physician orders in place. During an interview on 7/28/25 at 10:48 A.M., the Director of Nursing (DON) said that all medications and treatments require a Physician's order. The DON said that there were no Physician orders in place for Resident #29 to be administered oxygen therapy but there should have been an order in place.

Based on observations, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#54), out of one applicable resident receiving dialysis (process that filters waste and fluids from the blood when the kidneys are unable to work adequately) services, out of a total sample of 19 residents.Specifically, for Resident #54, the facility failed to ensure:-Timely medication administration on the Resident's scheduled dialysis days (Tuesdays, Thursdays, and Saturdays), when scheduled morning medication administration was delayed until after the Resident's return to the facility in the early afternoon on dialysis days.-That Eliquis (medication to prevent and treat blood clots), ordered to be administered twice daily by the Physician, was being administered at appropriate intervals on dialysis days placing the Resident at risk for complications related to bleeding.-Accurately monitor daily fluid intake, as ordered by the Physician, when the Resident was dependent on renal dialysis, placing the Resident at risk for complications related to fluid overload. Findings include: Review of Medscape Eliquis (apixaban) Professional Standards, retrieved from https://reference.medscape.com/drug/eliquis-apixaban-999805#91, indicated:-Take this medication by mouth with or without food as directed by your doctor, usually twice daily (every 12 hours). Review of the facility policy titled Hemodialysis, dated February 2018, indicated:-Purpose is to provide comprehensive care to resident/patients that receive hemodialysis treatments.-If Resident is placed on fluid restriction, monitor intake. Review of the facility policy titled Intake and Output Monitoring, dated February 2018, indicated:-Intake and Output will be monitored, as indicated by the resident's hydration status, risk for dehydration, and/or per physician's order.-Intake and Output is totaled daily by 3:00 P.M. to 11:00 P.M. shift nurse, and 24-hour totals are transcribed to the Medication Administration Record (MAR). Resident #54 was admitted to the facility in September 2023 with diagnoses of End Stage Renal Failure, Cognitive Communication Deficit, Hypoxemia, Major Depressive Disorder, Anxiety and dependent on dialysis. Review of the Minimum Data Set (MDS) Assessment, dated 5/6/25, indicated Resident #54:-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total of 15.-was receiving dialysis. Review Resident #54's Comprehensive Person-Centered Care Plan, revised 7/24/25, indicated the Resident was at risk for potential for fluid overload related to End Stage Renal Disease with need for Hemodialysis (HD). Further Review of the Care plan included interventions to monitor, document, and report to MD signs and symptoms of fluid overload, and fluid restriction as ordered with intake monitoring. Review of Resident #54's July 2025 Physician orders included:>Hemodialysis every Tuesday, Thursday, and Saturday, initiated 10/6/23.>Fluid Restriction 32 ounces (oz) per day, initiated 12/2/24:-12 to 16 oz with breakfast, 100 milliliters (ml) with medications-6 - 8 oz with lunch, 100 ml with medications-6 - 8 oz with supper, 100 ml with medications. >Intake and Output for dialysis/fluid management every shift for renal function, document at the end of the shift, initiated 12/2/24.>Apixaban (Eliquis) oral tablet 2.5 milligram (mg) give two tablets two times a day, initiated 11/4/24. Review of Resident #54's July 2025 Medication Administration Record (MAR) indicated:-Apixaban (Eliquis) 2.5 mg, give 2 tablets by mouth two times a day related to Paroxysmal Atrial Fibrillation, started 11/5/24, scheduled for 8:00 A.M. and 7:00 P.M. daily. During an interview on 7/24/25 at 11:20 A.M., Resident #54 said he or she was on dialysis and leaves the facility at 5:30 A.M. on Tuesdays, Thursday and Saturdays for dialysis treatment. Resident #54 said he/she received his/her morning medications including the Eliquis medication between the hours of 10:30 A.M. and 11:00 A.M., upon his/her return from dialysis. Resident #54 also said he/she was not on fluid restriction and that no staff member asks how much fluid he or she drank daily. During an interview on 7/24/25 at 11:45 A.M., Nurse #5 said she was an agency Nurse but worked regularly at the facility. Nurse #5 said Resident #54 had an order for a fluid restriction, but the Nurse had not monitored the Resident's fluid intake as the Resident was independent in his/her room. During an interview on 7/29/25 at 11:09 A.M., Nurse #1 said Resident #54 had an order for fluid restriction, but the Resident was independent in his/her room and that the Resident could monitor his/her own fluids. During an interview on 7/29/25 at 11:14 A.M., CNA #1 said Resident #54 was not on fluid restriction, and staff would document Resident #54's fluid intake on the Meal Percentage Documentation Sheet but would not report the Resident's fluid intake to the Nurses. During an interview on 7/29/25 at 2:55 P.M., the Director of Nursing Services (DNS) said she will get back to the surveyor after she had reviewed Resident #54's fluid intake documentation and medication orders. During an interview on 7/30/25 at 8:12 A.M., the DON said Resident #54 was on fluid restrictions, but the facility staff had not been consistent with monitoring the Resident's fluid intake. The DON said Resident 54's Eliquis medication was administered less than 8 hours apart on dialysis days, and the DON would follow-up with the Nurse Practitioner (NP) to review further orders. During a follow-up interview on 7/30/25 at 12:15 P.M., the DON said the NP had revised the order for Resident #54's Eliquis medications to be administered at different times on dialysis days to accommodate the Resident's dialysis schedule. The DON further said review of the Resident's medications/ dialysis schedule should have been completed when the Eliquis order was obtained but it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to ensure proper sanitation and food storage practices to prevent the potential spread of foodborne illnesses on two kitchenettes ([NAME] Unit and [NAME] Unit) out of two kitchenettes observed. Specifically, the facility failed to ensure that the [NAME] Unit and [NAME] Unit kitchenette refrigerators: -had food items that were dated to ensure proper rotation by expiration dates.-were kept clean and sanitized on a scheduled basis.-had food/drink items that were not expired or past the perish dates. Findings include: Review of the Facility Policy titled Refrigerators and Freezers, revised December 2014, indicated: -All food shall be appropriately dated to ensure proper rotation by expiration dates. -Expiration dates on unopened food will be observed and use by dates indicated once food is opened. -Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. -Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. On 7/30/25 at 10:27 A.M, the surveyor and the Food Service Director (FSD) observed the following in the [NAME] Unit kitchenette refrigerator: -A container of sour cream with an expiration date of 6/25/25. -A container of whole milk with an expiration date of 7/21/25 -2 containers of Instant Jello with expiration dates of 2/24/25 -Unlabeled and undated resident food items. -Spilled food items and debris on the refrigerator shelves. During an interview at the time, the FSD said that the Dietary Department does not maintain the kitchenette refrigerators on the [NAME] unit and the [NAME] unit and is not responsible for cleaning and maintaining the food in the refrigerators. The FSD said that the Dietary Department does not maintain a cleaning schedule for the kitchenettes because the housekeeping department is responsible for the cleaning of the refrigerators and making sure food items are not expired. On 7/30/25 at 10:30 A.M, the Housekeeping Director said he was employed by the facility two months ago, did not realize his department was responsible for kitchenette refrigerator cleaning and food items, and therefore did not have a cleaning schedule. On 7/30/25 at 10:37 A.M, the surveyor and the Housekeeping Director observed the following in the [NAME] Unit kitchenette refrigerator: -Resident food items including milk, yogurts, and juices, that were unlabeled and undated. -Boiled eggs in a paper cup that were undated, unlabeled, and uncovered. -Cut Lemons, ginger, and cucumbers, in a ziploc bag that were unlabeled and undated. -An open stick of butter, partially wrapped, that was undated and unlabeled. -An expired supermarket packaged Cobb salad with turkey and bacon, expired on 7/21/25, unlabeled. During an interview at the time, the Housekeeping Director said that the food items in the refrigerator appear to be some staff food and some resident foods, but he was unsure. The Housekeeping Director said that he was unaware that his department was responsible for the kitchenette refrigerator maintenance and food items. On 7/30/25 at 10:45 A.M., the Administrator said the Dietary Department should have been maintaining the refrigerator and checking daily for unlabeled or expired items in the [NAME] Unit kitchenette refrigerator, but this had not happened. The Administrator said that the [NAME] kitchenette refrigerator is for staff items only and should not contain resident items. The Administrator said the [NAME] kitchenette refrigerator should be maintained by nursing staff because the staff store food items there, but all food items should be dated and labeled, and no expired food items should ever be stored past the expiration dates. During an interview on 7/30/25 at 11:02 A.M the Administrator said having unlabeled, undated and expired items in the refrigerators puts residents at risk for foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain clinical records in accordance with professional standards of practice relative to accurate documentation for two Residents (#45 and #56) out of a total sample of 19 residents.Specifically, the facility failed to: 1.For Resident #45, document the PRN (as needed) administration of Tramadol (opioid analgesic - controlled medication used to treat pain, having the potential for abuse and addiction), and its effectiveness, on the Resident's Medication Administration Record (MAR) when a PRN dose of Tramadol was administered to the Resident. 2. For Resident #56, the facility failed to complete accurate documentation relative to changing the Resident's Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: 1.Review of the facility's policy titled Medication Pass, dated April 2018, indicated the following: - Med (medical) record is initialed immediately after medication administration. - PRN (as needed) meds must state reason given, and the results on the MAR. Resident #45 was admitted to the facility in October 2022 with diagnoses including Chronic Pain Syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #45: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 total possible points. -reported pain presence as almost constantly. -reported his/her pain occasionally affected his/her sleep and day to day activities. -received opioid medication during the observation period for the MDS Assessment. During an interview on 7/24/25 at 11:41 A.M., Resident #45 said he/she had chronic pain and was able to request Tramadol on an as needed (PRN) basis to treat his/her pain. Review of Resident #45's July 2025 Physician orders indicated the following: -Tramadol HCl Oral Tablet 50 milligrams (mg) by mouth every 12 hours as needed for pain, initiated 3/17/25. Review of the [NAME] Unit Narcotic Book, page three, indicated PRN Tramadol was administered to Resident #45 in July 2025 as follows: -7/11/25 at 10:00 A.M. and again at 10:00 P.M. -7/13/25 at 9:30 P.M. -7/16/25 at 10:30 P.M. -7/18/25 at 9:30 A.M. Review of Resident #45's July 2025 MAR indicated PRN Tramadol was administered to the Resident as follows: -7/11/25 at 10:00 A.M. and again at 10:00 P.M. for pain levels of 8/10 and was effective. -7/13/25 at 9:30 A.M. for a pain level of 8/10, and was effective -7/18/25 at 9:29 A.M. for a pain level of 8/10 and was effective. -No evidence PRN Tramadol was administered to the Resident on 7/16/25 at 10:30 P.M., as indicated in the Narcotic Book. Review of Resident #45's clinical record failed to indicate any evidence that one dose of PRN Tramadol medication was administered to the Resident at 10:30 P.M. on 7/16/25. During an interview on 7/29/24 at 10:47 A.M., Nurse #4 said she worked at the facility for the evening (3:00 P.M.-11:00 P.M.) shift on 7/16/25 and was assigned to provide care for Resident #45. Nurse #4 said she included one dose of PRN Tramadol in the Resident's regularly scheduled 10:00 P.M. medications because the Resident was having pain. Nurse #4 said she administered the medications to Resident #45 as ordered, and the Resident accepted the medication, including the PRN Tramadol. Nurse #4 said that she should have documented the PRN Tramadol administration on Resident #45's MAR when she administered the Tramadol to the Resident. Nurse #4 also said she should have documented whether the PRN Tramadol was effective for treating the Resident's pain. During an interview on 7/29/25 at 1:34 P.M., the Director of Nursing (DON) said Nurses were required to document administration of all medications on each Residents' MARs. The DON said Nurse #4 should have documented the dose of PRN Tramadol administered on 7/16/25 at 10:30 P.M. to Resident #45 on the Resident's MAR. The DON also said that Nurse #4 should also have documented whether the Tramadol was effective for treating the Resident's pain. The DON said documenting the administration and effectiveness of PRN pain medication was important to ensure the pain medication was effective for the Resident. 2.Review of the facility policy titled Catheterization Foley, dated April 2018, indicated: -Indwelling urinary catheters are used only when there is valid medical justification. -The Foley catheter will be changed only when needed, unless otherwise specified by the Physician, Nurse Practitioner (NP), or Physician Assistant (PA). -Foley catheters should be changed when: <urinary tract infection is suspected <clogged or unable to irrigate <displaced (balloon [retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body] suspected to be in urethra) <resident discomfort <MD (Medical Doctor/Physician) order 2. Resident #56 was admitted to the facility in May 2024 with diagnoses including urinary retention and obstructive and reflux uropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #56: -was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15. -had an indwelling urinary catheter. -was dependent on staff for activities of daily living (ADL's - basic skills such as bathing, dressing, eating, etc.). Review of Resident #56’s July 2025 Physician orders indicated: -Foley catheter 16 French [Fr]/10ml balloon, change PRN for signs and symptoms of infection, one time a day starting on the 10th every month related to retention of urine, initiated 4/10/25. On 7/25/25 at 10:31 A.M., the surveyor and Nurse #5 observed Resident #56’s foley catheter and Nurse #5 said the size of the Foley catheter was 14 Fr, and the balloon size label had faded and was unreadable. On 7/25/25 at 10:35 A.M., the surveyor and Nurse #5 reviewed Resident #56’s Foley catheter order and Nurse #5 said the Foley catheter ordered for Resident #56 was 16 Fr and 10 ml balloon. The surveyor and Nurse #5 reviewed the Treatment Administration Record (TAR) and Nurse #5 said the TAR indicated that Resident #56’s Foley catheter had been changed on 7/10/25 and signed off by a Nurse as size 16 Fr and 10 ml balloon. During an interview on 7/25/25 at 10:39 A.M., the Director of Nursing (DON) reviewed the TAR for May 2025, June 2025, and July 2025 and said that Nurses had signed off that Resident #56’s Foley catheter had been changed on 5/10/25, 6/10/25, and 7/10/25, to 16 Fr/10 ml balloon, but the Nurses had not provided the Foley catheter care but had signed off as care provided. During an interview on 7/29/25 at 8:59 A.M., Nurse #1 said she had signed off the TAR as having changed Resident #56’s Foley catheter to 16 Fr/10 ml balloon on 6/10/25 and 7/10/25, but she did not change the Foley catheter and the TAR record was inaccurate.

Based on observation, interview, record and policy review, the facility failed to implement an infection control program designed to help prevent the potential transmission of communicable diseases and infections within the facility for one Resident (#6) out of a total sample of 19 residents. Specifically, the facility staff failed to disinfect a multi-use Glucometer (machine used to test a resident's blood for blood sugar levels) after use on a resident, prior to placing the same equipment back into the medication cart. Findings include: Review of the facility policy titled Infection Control, revised October 2018, indicated but was not limited to:-The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.-The objectives of our infection control policies and procedures are to:>prevent, detect, investigate, and control infections in the facility.>provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of the facility provided Operators Manual titled, Cleaning and Disinfecting your Evencare G2 Meter, undated, indicated but was not limited to:-The following products are validated for disinfecting the Evencare G2 Meter:>Dispatch Hospital Cleaner disinfectant towels with Bleach>Medline Micro-kill>Clorox Healthcare Bleach Germicidal and Disinfectant wipes>Medline Microkill Bleach Germicidal Bleach wipes Resident #6 was admitted to the facility in March 2015 with diagnoses including Chronic Respiratory Failure, Tracheostomy (surgical procedure that involves creating an opening in the neck to place a tube into a person's trachea, or windpipe to assist with breathing), Gastrostomy Tube Placement (G-tube), and Type 2 Diabetes. Review of the Resident #6's July 2025 Medication Administration Record (MAR) indicated:-Fingerstick blood sugar check weekly in the morning every 7 days related to Type 2 Diabetes Mellitus. On 7/29/25 at 8:29 A.M., the surveyor observed the following:-Nurse #1 removed the Glucometer machine from a case in the top drawer of her medication cart.-Nurse #1 performed hand hygiene and donned Personal Protective Equipment (PPE), including gown and gloves prior to entering Resident #6's room. -Nurse # 1 performed the finger stick on Resident #6 using the glucometer and then placed the glucometer on the Resident's bedside table. -Nurse #1 removed her gown and gloves, performed hand hygiene, and disposed of the lancet in the sharps disposal container.Nurse #1 removed Lysol wipes from the medication cart and wiped the glucometer device before placing it back in the case and in the top drawer of the medication cart. During an interview immediately following the observation, Nurse #1 said that she always uses the facility provided Lysol wipes to clean the glucometer and uses the same glucometer on multiple residents. Nurse #1 said that she was not aware of any other cleaning product that should be used on the glucometer device. During an interview on 7/29/25 at 10:16 A.M., with the Director of Nursing (DON) and Infection Preventionist (IP), the IP said Nurses should be using a bleach wipe to clean the glucometer immediately, allowing a 2-minute dry time, before placing it back in the medication cart. The DON said the facility started using a newer glucometer several months ago and should have been following the manufacturers guidelines that indicate a bleach product should be used to clean the glucometer. The DON said that the facility Policy and Procedure titled Glucometer Cleansing and Disinfecting Policy is outdated and was not updated when it should have been, and the facility was following the Evencare G2 Meter Operators Manual that indicated a bleach cleaner should be used to clean the glucometer. During an interview on 7/29/25 at 10:35 A.M., the IP said that Nurse #1 should have used bleach wipes for the glucometer to prevent the transmission of blood borne pathogens from one resident to another but used Lysol wipes which did not contain bleach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to assess the Pneumococcal Vaccine status, and/or administer Pneumococcal vaccinations as consented to by two Residents (#11 and #9), of five applicable residents, out of a total sample of 19 residents.Specifically, 1. For Resident #11, the facility failed to assess for Pneumococcal consent or declination for the Resident and to provide education relative to Pneumococcal vaccination at the time of admission. 2. For Resident #9, the facility failed to obtain a Physician's order and administer PCV 20 (Pneumococcal Conjugate Vaccine/ Prevnar 20: vaccine used to protect against 20 types of pneumococcal bacteria that commonly cause serious infections) at the time of admission when the Resident consented to PCV20 vaccination. Findings include: Review of the facility's policy titled Pneumococcal Vaccination dated April 2018, indicated but was not limited to the following: -It is the policy of the facility that Pneumococcal Vaccine will be offered to every new resident admitted to this facility, and all new residents not previously immunized will be encouraged to receive the vaccination to help prevent the occurrence of Pneumococcal pneumonia and/or its complications. -Upon admission to this Center each new resident will be provided with a copy of the most recent Vaccine Information Sheet (VIS) . -The completed consent (form) and VIS . will be placed in the resident's record. -A Physican order will be obtained to administer the vaccination. -If the resident/responsible party is uncertain about previous vaccination status the vaccine should be administered. Additional doses are not detrimental. -The Infection Control Nurse .will record the following information on the residents Pneumonia Vaccine Log: resident name/consent form completed/acceptance or declination of vaccination/reason vaccine not administered/date vaccine administered. Review of the Centers for Disease Control (CDC) and Prevention Guidance on Pneumococcal Vaccine Timing for Adults, dated October 2024, included but was not limited to the following: For Adults [AGE] years old or older, vaccine recommendations are as follows: -Unvaccinated adults should receive: a) PCV20 (Prevnar 20) or PCV21 vaccine or b) PCV15 followed by PPSV23 at least one year later -Adults who have received PPSV23 vaccine only (at any age): a) PCV20 or PCV21 vaccine administered at least one year after PPSV23 was received -Adults who have received PCV13 vaccine at any age: a) PCV20 or PCV21 vaccine administered at least one year after PCV13 was received -Adults who have received PCV13 at any age and PPSV23 when younger than age [AGE]: a) PCV20 or PCV21 at least 5 years after PCV13 or PPSV20 vaccine was received 1.Resident #11 was admitted to the facility in March 2025, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) with Lower Respiratory Infection and Chronic Respiratory Failure. Review of the most recent Minimum Data Set (MDS) Assessment with a reference date of 3/17/25, indicated Resident #11: -was cognitively intact as indicated by a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15.-Pneumococcal vaccination status was not up to date. -the Pneumococcal vaccine had not been offered to the Resident by the facility. Review of Resident #11's medical record included but was not limited to: -A blank Pneumococcal Immunization Form signed by the Resident and dated 3/2/1959 [sic]. -Evidence of prior Pneumococcal vaccination with PCV13 in September 2017. During an interview on 7/28/25 at 1:30 P.M., the Director of Nursing (DON) said that she was responsible for completion of vaccine consent forms for Resident #11. The DON said that Resident #11 did not have evidence of Pneumococcal consent or declination in his/her medical record but should have. The DON said that the Resident had not yet been offered or educated on the Pneumococcal vaccination as required but should have been. 2. Resident #9 was admitted to the facility in March 2025 with diagnoses including COPD and Chronic Respiratory Failure. Review of the most recent MDS Assessment with a reference date of 6/17/25, indicated Resident #9's: -Pneumococcal vaccination status was not up to date. -Pneumococcal vaccine had not been offered by the facility. Review of Resident #9's medical record included but was not limited to: -A signed Pneumococcal Immunization consent form dated 3/13/25. -Evidence of prior vaccination with PCV13 in November 2016. -No evidence that the Pneumococcal Vaccine had been administered as requested or that a shared clinical decision had occurred relative to Pneumococcal vaccination for Resident #9. During an interview on 7/28/25 at 4:26 P.M., the DON said that she was unable to provide evidence that a shared clinical decision had occurred or that a Pneumococcal Vaccination had been provided as consented to by the Resident at the time of his/her admission. During an interview on 7/29/25 at 10:42 A.M., the DON said that Resident #9 should have had a shared clinical decision making on whether or not the PCV20 or PCV21 should have been given within one week of admission but did not. The DON said that she was ultimately responsible to ensure that Pneumococcal Vaccination is offered per CDC guidelines for consenting Residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to maintain a clean and homelike environment for one Resident (#56) and 12 out of 15 rooms observed on two Units ([NAME] and [NAME]) out of two resident units. Specifically, the facility failed to ensure that room of the day deep-cleaning were completed relative to the room of the day cleaning schedule for:-Resident #56's bedroom.-rooms [ROOM NUMBER] on the [NAME] Unit.-Rooms 201, 202, 204, 206, 207, 208, 209, 221, and 224 on the [NAME] Unit. Findings include: Review of the facility policy titled Room of The Day, revised February 2021, included but was not limited to: -Residents are provided with safe, clean, comfortable and homelike environment. -The staff and management develop room of the day schedule for terminal cleaning of rooms to assure rooms are clean, sanitary, comfortable . -Strip bed and remove linen. -Clean all furniture. -Sweep/mop floors. -Remove curtains, clean above windowsills, light fixtures, fans, etcetera. Resident #56 was admitted to the facility in May 2024 with diagnoses including Alzheimer's Disease. Review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE], included but was not limited to the following:-severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of a total possible 15 points. On 7/25/25 at 1:39 P.M., Resident #56's Resident Representative (RR #1) requested to meet with surveyor #1 in the Resident's room. During an interview at the time, RR #1 said that he/she was concerned that the staff did not dust or clean the resident rooms. RR #1 was observed to swipe his/her hand across the top of Resident #56's television, with resulting thick dark gray dust accumulated on his/her fingertips. RR #1 further said that he/she had spoken with the facility administration about Resident #56's room cleaning concerns. During an interview on 7/29/25 at 9:01 A.M., surveyor #2 and the Director of Housekeeping discussed that each day the housekeeping staff should complete the room of the day cleaning according to the established facility schedule. The Director of Housekeeping said that the room of the day cleaning was a special deep cleaning procedure which included removal of privacy curtains for washing, resident furniture to be pulled to the center of the room, all surfaces get cleaned and disinfected, floors get swept and washed, and all high dusting zones should be dusted including the over the bed light fixtures. At this time, surveyor #2 and the Director of Housekeeping observed the Room of The Day cleaning schedule for July 2025 which indicated the following rooms and dates the rooms were cleaned: -room [ROOM NUMBER] and room [ROOM NUMBER]: on 7/14/25 -room [ROOM NUMBER] and room [ROOM NUMBER]: on 7/28/25 -room [ROOM NUMBER] and room [ROOM NUMBER]: on 7/16/25 -room [ROOM NUMBER]: on 7/15/25 -room [ROOM NUMBER]: on 7/24/25 -room [ROOM NUMBER]: on 7/21/25 -room [ROOM NUMBER]: on 7/23/25 -room [ROOM NUMBER]: on 7/11/25 -room [ROOM NUMBER]: on 7/27/25 -room [ROOM NUMBER]: on 7/18/25 -room [ROOM NUMBER]: on 7/22/25 -room [ROOM NUMBER]: on 7/25/25On 7/29/25 at 11:47 A.M., surveyor #2, the Director of Housekeeping, the Director of Nursing (DON), and the Infection Preventionist (IP) observed the following 15 rooms for cleanliness: Rooms 201, 202, 203, 204, 206, 207, 208, 209, 212, 215, 216, 220, 221, 223 and 224. The following 12 rooms: Rooms 201, 202, 204, 206, 207, 208, 209, 212, 215, 216, 221, and 224 were observed to have thick fibrous coating of dust on the overbed light fixtures. The Director of Housekeeping, DON and IP said that the light fixtures were dusty. The Director of Housekeeping said that the 12 rooms had not been terminally cleaned according to The Room of The Day schedule for July 2025 for various reasons. The Director of Housekeeping said that he was unable to provide evidence of when these 12 rooms had last been terminally cleaned. The DON and IP said that there was no process in place for monitoring the cleanliness of the facility's environment but that there probably should be. During an interview on 7/29/25 at 2:00 P.M., the Administrator said he was unaware that Rooms 201, 202, 204, 206, 207, 208, 209, 212, 215, 216, 221, and 224 had not been terminally cleaned according to the facility's established schedule. The Administrator said that he should have been informed by the Director of Housekeeping when rooms had been skipped during morning report or via text message the following day. The Administrator said that skipped rooms should be terminally cleaned the following day when skipped. The Administrator said that he was unaware of ongoing concerns related to resident room cleanliness. During an interview on 7/30/25 at 8:39 A.M., the DON said that there was a family member a long time ago that had expressed concerns related to high dusting zone areas, and she had reported it to the Administrator. The DON said she was unable to recall which family member had the dusting zone concerns or exactly when the concerns had been brought forward.

Based on interview and record review, the facility failed to ensure that a Resident's choices were honored when requested by his/her Resident Representative for one Resident (#14) out of a total sample of 18 residents. Specifically, the facility failed to evaluate whether the Resident Representatives' request for Resident #14 to receive double meal portions was appropriate for him/her, and implement the request if it was determined to be appropriate for the Resident indicated by family as always being hungry. Findings include: Resident #14 was admitted to the facility in June 2019, with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). During an interview on 4/30/24 at 12:01 P.M., Resident Representative #1 said he/she had requested double meal portions for Resident #14 on multiple occasions. Resident Representative #1 said when family visited with Resident #14, he/she was always hungry. Resident Representative #1 further said that he/she had not been provided with follow -up from facility staff on the request for double meal portions, and he/she was unsure if the request had been addressed. Review of the Nursing Progress Note dated 11/30/23, indicated that the Resident Representative had spoken with nursing and requested meal portions be increased. Review of the Resident's Current Diet Order and Communication slip provided by the facility's kitchen, dated 4/29/23, did not indicate that Resident #14 received double meal portions. During an interview on 5/1/24 at 11:55 A.M., the Food Service Director (FSD) said Resident #14 received single portion meals and that she was not made aware that the Resident's Representative had requested double portions for meals. The FSD further said when a request for increased portions was made, she would let the Dietitian know and the Dietitian would then have assessed whether the Resident was appropriate for increased portions, but no one had made her aware of Resident #14's request. During an interview on 5/1/24 at 12:17 P.M., the Dietitian said she was unaware that Resident #14's Resident Representative had requested double meal portions for the Resident. The Dietitian further said when someone requests increased meal portions, she would evaluate whether increased portions were appropriate for the Resident. The Dietitian said if the Resident was not appropriate for increased meal portions, she would provide the Resident Representative with education on why increased meal portions were not appropriate and get further feedback from the Resident Representative on why they felt the Resident needed increased meal portions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that care plans were developed and implemented accordingly for one Resident (#14) out of a total sample of 18 residents. Specifically, -For Resident #14 the facility failed to develop a care plan related to the Resident's behavior of eating nonfood items and topical medications. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated the following: -The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Resident #14 was admitted to the facility in June 2019 with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of a Nursing Progress Note dated 7/26/23, indicated that Resident #14 was found eating the foil covering off of his/her applesauce cup. Review of a Nursing Progress Note dated 11/10/23, indicated that Resident #14 had ingested [NAME] Lotion (an anti-itch topical [applied to the skin] medicated lotion). Review of a Nursing Progress Note dated 3/30/24, indicated that Resident #14 had ingested a calamine (anti-itch topical medication), hydrocortisone (an anti-itch topical mediation), zinc paste (a skin protectant topical medication) mixture (the facility's house barrier cream [a cream used as a skin protectant]). During an interview on 4/30/24 at 11:58 A.M., Resident Representative #1 said Resident #14 had a tendency to eat nonfood items and that Resident Representative #1 made sure the Resident did not have items within his/her reach that he/she could put into his/her mouth. During an interview on 5/1/24 at 12:06 P.M., with Nurse #1 and Certified Nurses Aide (CNA) #1, Nurse #1 said Resident #14 had a tendency to eat nonfood items. CNA #1 said staff could not leave any items within the Resident's reach as he/she would put them in his/her mouth. CNA #1 further said said staff needed to make sure items such as the Resident's meal ticket or tops that were removed from containers of food were taken off his/her meal tray or he/she would put those items in his/her mouth. Review of Resident #14 care plan indicated no documented care plan addressing the behavior of eating nonfood items and interventions that should be used to deter the Resident from eating nonfood items. During an interview on 5/1/24 at 2:56 P.M., the Director of Nurses (DON) said Resident #14 did not have a care plan in place that addressed the eating of nonfood items. The DON further said any time a resident had a behavior that required intervention a care plan should be developed so staff is aware of how to provide interventions for the behavior, and this was not done for Resident #14. Please Refer to F761

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy and record review, the facility failed to provide nutrition care and services that meet professional standards of practice in identifying and preventing a significant weight loss for one Resident (#65) recieving artificial nutrition via a Jejunostomy tube (J-Tube: a feeding tube that passes directly into the small intestine), out of a total sample of 18 Residents. Specifically, the facility staff failed to: -appropriately implement, monitor and evaluate weekly weights as ordered for the Resident, and reassess Resident refusal to be weighed. -assess tube feeds recommendations made by the Registered Dietitian (RD), and refer and/or offer alternative options when the Resident was unable to tolerate increased tube feeds and calorie goals. Findings Include: Review of the Professional Standards of Practice in the [NAME] NURSING PROCEDURES, 9th edition 2023, indicates the following relative to Enteral (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) .Jejunal tube feedings: -Monitor the patient's weight and nutritional, fluid, electrolyte, and metabolic status, as ordered, to evaluate the effectiveness of enteral feedings. Review of the facility policy titled Nutritional Services, reviewed October 2023, indicated the following: -The height and weight of residents is measured upon admission to the facility. Following admission residents are weighed weekly x 4 weeks, then monthly and as needed per doctor order. -Residents are weighed upon readmission to the facility and the decision to initiate weights weekly based on significant weight loss/gain triggers. -Weights are verified and documented in the medical record as they are obtained. -Check the previous monthly weight for any significant change. If there is a significant change of + or - 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, the resident should be re-weighed within 24 hours. -Diets and fluids are provided as ordered and as appropriate to meet estimated needs. -Residents are encouraged to be involved with their care as able and opportunities for education are addressed. Review of the facility policy titled Weights, revised February 2017, indicated the following: -The weight of each resident will be monitored on a regular basis no less than monthly. Weight monitoring on a regular basis will allow for identification of weight changes and subsequent appropriate care planning and evaluation. -All residents will be weighed within 24 hours of admission/readmission and then weekly for the next three weeks for a total of four weeks. -All residents will be weighed monthly by the 7th of each month. -The Nursing Assistants will record the weights on the Weight Sheet. -The Unit Manager will document the weights directly into the weight book which is kept on each unit. -A weight gain or loss of 5 lbs or more will require the Unit Manager to notify the Dietician . -The Dietician will review all monthly weights and report to the IDT (Interdisciplinary Team) any significant changes in the resident's weight. -The Dietician will make the determination if the resident needs to be weighed on a more frequent basis. -Residents that have experienced a significant weight loss will be reviewed by the IDT to determine the root cause . Resident #65 was admitted to the facility in December 2023, with diagnoses including severe protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients the body gets), malignant neoplasm of esophagus (cancer in the tube from the mouth to the stomach), Dysphagia (difficulty swallowing), and received artificial nutrition via a Jejeunostomy tube (J-Tube). Review of the full Nutrition Risk Assessment, dated 12/16/23, indicated the following: -Resident #65's ideal body weight was 160 lbs -Resident originally went to the hospital in August 2023, with reports of 45 lb weight loss x3 months -Resident's most recent weight was 127.0 pounds (lbs.) on 12/12/23 -Discharge (DC) instructions from the Hospital were tube feedings Vital AF 1.2 @ 85 ml/hr to progress over 16 hours, and increase 10 ml (milliliters) daily to goal of 105 ml/hr as tolerated. -Recommend 100 ml H20 (free water) flushes Q (every) 8 hrs. Review of the Progress Notes by the Physician and Nurse Practitioner (NP) indicated the following: 12/13/23 - Unexplained weight loss of greater than 45 pounds. Continue tube feedings as scheduled. We will monitor patient's weight closely work with the Dietician to optimize patient's nutritional status. 12/27/23 - Continue tube feeding at 85 ml/hr for 16 hours a day. 1/19/24 - Patient currently on tube feeds due to dysphagia for malignant neoplasm of the esophagus. Staff reports that he/she has not been meeting nutritional goals. We will follow-up with Nutritionist to review tretament plan and make recommendations. Continue to monitor weight and adjust tube feeds per nutrition recommendations. 1/24/24 - Spoke with patient. We will increase [tube] feed rate to 83 ml/hr, goal is to have patient greater than 100 ml an hour, however he/she has difficulties tolerating the tube feed. We will slowly upward titrate his/her rate as tolerated. 1/25/24 - Patient has not been tolerating the increased rate of 83 ml/hr. He/she is requesting to go back to 80 ml/hr. As it stands, current feed is not meeting his/her nutritional needs or goals. We will dial back to 80 ml/hr. Additionally recommended increase rate over less period of time however [patient] is not agreeable to this. Continue tube feeding at 80 ml/hr for 16 hours a day. 2/29/24- Continue with tube feeds at 80 ml/hr. Continue to monitor weight and adjust regimen as needed, follow-up with Nutritionist. 3/5/24 - Continue with tube feeds at 80 ml/hr. Continue to monitor weight, follow-up with Nutritionist as needed. 3/14/24 - Continue with tube feeds at 80 ml/hr. Continue to monitor weight, follow-up with Nutritionist as needed. Review of the full Nutritional Risk Assessment, dated 3/18/24, indicated the following: -Resident's ideal body weight was 160 lbs -Resident originally went to hospital in 8/23 with reports of 45 lb weight loss x3 months -Resident's most recent weight was 122.0 on 2/14/24 -Plan to monitor and evaluate weight, intake and tolerance, and nutrition related labs -Assessment that weight has been stable since admission in 12/23 -Discharge (DC) instructions from the Hospital were tube feedings Vital AF 1.2 @ 85 ml/hr to progress over 16 hours and to increase 10 ml daily to goal of 105 ml/hr as tolerated. -Recommend Vital AF 1.2 @ 85 ml/hr over 16 hours and to increase 10 ml daily to goal of 105 ml [per hour] as tolerated and 100 ml H20 water flushes Q8 hrs. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the following: -The Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15. -The Resident had a diagnosis of Malnutrition -No weight was available for the past 30 days -The Resident had Tube Feeds for artificial nutrition -The Resident received more than 51% of total calories via tube feeding -The Resident received more than 501 cc (cubic centimeters or milliliters (ml)) per day or more of fluids via tube feeding -The Resident did not demonstrate any behaviors or refusals of care Review of the April 2024 Physician's orders indicated the following: -Enteral (passing through the intestine in an artificial opening): Vital AF 1.2 cal (calorie) liquid via feeding tube THROUGH JEJUNOSTOMY PORT, hung up at 0600 (6:00 A.M.) and taken down at 2200 (10:00 P.M.), given via feeding pump set at 80 ml/hr one time a day and remove per schedule; active, initiated 1/25/24 -Enteral: Flush gastric [sic] tube with 30 ml of water before and after medication administration. Meds and flushes given through Jejunal port every shift; active, initiated 3/26/24 -Enteral: Flush Jejunal tube with 5 ml of water in between each medication administered through gastric [sic] tube every shift; active, initiated 3/26/24 -Nutrition Evaluation; active, initiated 2/21/24 -Weekly weight every day shift every Wed (Wednesday) for monitoring; active, initiated 2/24/24 Review of the Resident's Weight and Vitals Summary indicated the following weights: -12/12/23: 127 lbs [admission Weight] -1/1/23: 116.6 lbs -1/12/24: 117.5 lbs (-7.8% change since 12/12/23) -2/14/24: 122 lbs (+3.8% change since 1/12/24, -3.9% change since 12/12/23) -5/1/24: 111.6 lbs (pounds) (-8.5% change since 2/14/24, and -12.1% change since 12/12/23) Review of the Medication Assisted Treatment Records for February 2024, March 2024, and April 2024 relative to weekly weights indicated the following: -2/14/24: 122 lbs -No weights were obtained on the following Wednesdays: 3/6/24, 3/13/24, 3/20/24, 3/27/24, 4/3/24, 4/9/24, or 4/23/24. Review of the Nursing Progress Notes indicated the Resident refused to be weighed on 3/6/24, 3/20/24, 3/27/24, 4/3/24, 4/9/24 and 4/10/24. Further review of the Nursing Progress Notes did not indicate reasons why a weight was not obtained on 3/13/24 or 4/23/24. Review of the Resident's Tube Feeding plan of care, initiated 12/12/23 and last revised 4/2/24, indicated the following interventions: -dependent with tube feeding and water flushes. See MD orders for current feeding orders. -RD (Registered Dietitian) to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. -Discuss with [Resident]/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Review of the Nutrition Progress Note dated 4/20/24 indicated the following: -Registered Dietician (RD) met with Resident #65 at his/her request. -Resident desired to gain weight. -Resident refuses care and refuses to be weighed. -Resident was educated on the need to obtain an accurate weight to assess tube feeding requirements. -Resident agreed to let nursing weigh him/her. Review of the Nutrition Note dated 5/2/24 indicated: -Resident #65 weighed 111.6 lbs (-8.5% change since 2/14/24, and -12.1% change since 12/12/23) -Weight loss was noted and recommend increasing tube feedings as tolerated, see full [Nutrition] assessment (dated 3/18/24) for recommendations. Further review of the Nutritional Risk Assessment (3/18/24) and Nutrition Progress Notes (4/20/24) did not indicate: -that the Resident refusals to be weighted weekly (between 2/14/24 - 4/20/24) were addressed and Resident education provided prior to 4/20/24. -any interventions occurred to increase the tube feed rate. -that the increased tube feed rate was not tolerated by the Resident. -that weight loss was unavoidable due to disease progression or illnesses. -consistent RD monitoring of weights and tube feed goals, and/or re-assessment of the Resident nutritional status. During an interview on 5/1/24 at 1:03 P.M., the RD said that she is in the facility for 8 hours a week, that staff contact her via email or phone regarding diet changes, and she coordinates with the NP. The RD said that Resident #65 was admitted to the facility on the tube feeds and his/her diagnosis was poor. The RD said the NP contacted her about the Resident wanting to gain weight and she met with the Resident on 4/20/24. The surveyor and the RD reviewed the Resident's weights including the weight obtained on 5/1/24 at 111.6 lbs. The RD said she has concerns about weight loss and will review and discuss with the NP. The RD said that the Resident's nutritional needs are not being met if his/her goal is to gain weight and that he/she refuses to be weighed. During an interview on 5/1/24 at 2:49 P.M., Nurse #3 said staff perform weekly weights on Wednesdays and that Resident #65 often refuses weights. The Nurse said if Resident #65 refuses, staff would re-approach later in the day, and then if he/she continues to refuse to be weighed, staff would defer weights until the next week. Nurse #3 said that any refusal of weights would be documented in the Medication Administration Record (MAR) and Progress Notes. During an interview and observation on 5/2/24 at 10:26 A.M., Resident #65 said that he/she was concerned about his/her weight and would be willing to trial an increase in his/her tube feedings. The Resident said his/her goal on admission to the facility was to stabilize medically to participate in chemotherapy or other treatments to improve. Resident #65 said that he/she does feel that the medical staff in the facility have listened to his/her wishes. The surveyor observed the tube feeding of Vital AF 1.2 was connected and running at a rate of 80 ml/hr. During an interview on 5/2/24 at 11:25 A.M., CNA #3 said that resident weights are typically done at 6:00 A.M. and the Nurse provides a list of residents who need weights obtained. CNA #3 said if a resident refuses to be weighed, she will approach the resident three times and let the Nurse know if the resident refuses to be weighed. CNA #3 said the Nurses document the refusal of weights in the Nursing record. CNA #3 said that Resident #65 has had a decline and often refuses to be weighed. During an interview on 5/2/24 at 11:47 A.M., the NP said she spoke with Resident #65 today after he/she had an updated weight and the Resident expressed concerns about his/her weight. The NP said the Resident's current nutrition needs are not being met. The NP further said that if a Resident is refusing weights, then she would expect that staff would document approaching the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated the following procedure: -When equipment is completely dry, store in a plastic bag with the Resident's name and date on it. -Change equipment every 7 days, or according to the facility protocol. Resident #3 was admitted to the facility in September 2018 with diagnoses of Chronic Respiratory Failure (CRF - long term condition in which airways are damaged limiting movement of air through the body), Chronic Obstructive Pulmonary Disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and restricted air flow), and Congestive Heart Failure (CHF - a condition where your heart cannot pump enough blood to meet your body's needs). Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15. Review of the April 2024 Physician's orders indicated the following: -Oxygen continuous with Special Directions to titrate to maintain O2 SATS >90%, every shift for Shortness of Breath and O2 Sat Results, active, start date 11/12/20 -Ipratropium-Albuterol Solution 0.5 - 2.5 (3) mg/3 ml, inhale orallyin the evening related to Acute and Chronic Respiratory Failure With Hypoxia, active, start date 5/17/23 -Nebulizer mask and tubing changed weekly one time a day every Fri (Friday) related to COPD, active, initiated 11/13/20 -Oxygen tubing changed weekly every night shift every Fri (Friday) date, active, initiated 11/13/20 Review of the April 2024 Treatment Administration Record (TAR) indicated that the nebulizer mask and tubing and the oxygen tubing were changed on (Friday) 4/26/24. During an interview and observation on 4/30/24 at 8:54 A.M., the Resident said the staff did not change the oxygen tubing. The surveyor observed that the oxygen tubing and the nebulizer tubing were dated 4/23/24. The surveyor also observed that the nebulizer tubing and nebulizer mask were placed directly on the Resident's bedside table. On 5/1/24 at 8:04 A.M., the surveyor observed Resident #3 seated in a wheelchair in the hallway receiving Oxygen therapy. The surveyor observed that the oxygen tubing was dated 4/23/24. On 5/2/24 at 9:41 A.M., the surveyor observed Resident #3 seated in a wheelchair in his/her room receiving Oxygen therapy. The surveyor observed that both the oxygen tubing and the nebulizer tubing were dated 4/23/24, and that the nebulizer tubing and mask were placed directly on the Resident's bedside table. During an interview on 5/2/24 at 9:41 A.M., Nurse #2 said the Resident should have the nebulizer mask and tubing in a bag, but the Resident currently did not have a bag. Nurse #2 said she was aware the current nebulizer mask and tubing and oxygen tubing needed to be changed. During an interview on 5/2/24 at 12:40 P.M., the Director of Nurses (DON) said nebulizer masks and tubing and oxygen tubing should be changed weekly and kept at the bedside. The DON said she was not aware of how [nebulizer] tubing and masks should be stored when not in use. Based on observation, interview, policy and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#272 and #3), out of 3 applicable residents, out a total sample of 18 residents. Specifically, the facility staff failed to: 1) For Resident #272, a) ensure that the aerosol compressor (a large volume nebulizer that is used in tracheostomy patients to deliver a high-volume mist that moisturizes/ humidifies the airway) was monitored and maintained for optimal humidification of the Resident's tracheostomy ( an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) tube, b) ensure a Physician's order was obtained for oxygen use and increased liter flow, and c) that oxygen tubing equipment was changed as required to prevent contamination and the spread of infections. 2) For Resident #3, change oxygen tubing and nebulizer tubing and mask as ordered to ensure that the respiratory equipment were maintained in a sanitary manner to prevent the spread of organisms and infections. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia [high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: All oxygen delivery equipment should be checked at least once daily Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. 1) Resident #272 was admitted to the facility April 2024 with diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Malignant Neoplasm of Larynx (cancer of the vocal cords), Chronic Obstructive Pulmonary Disease (COPD- chronic lung disorders resulting in blocked air flow in the lungs and breathing problems) and required the use of a Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) tube. Review of the Progress Note on 4/17/24 by the Medical Physician indicated the Resident had a Tracheostomy tube placed in the hospital due to respiratory failure. Review of the April 2024 Physician's orders failed to indicate the parameters for oxygen use, humidifier/aerosol use, monitoring the Resident's response to oxygen therapy, or the maintenance schedule of oxygen and tracheostomy humidification equipment. Review of the Resident's Tracheostomy Plan of Care, initiated 4/18/24, indicated the following: -[The Resident] had a Tracheostomy related to impaired breathing techniques. -The goal was to have no signs or symptoms of infection through the next review date. -Interventions include monitoring/document for restlessness, agitation, confusion, increased heart rate (tachycardia) and bradycardia (reduced heart rate). -Intervention to monitor/document respiratory rate, depth, and quality. Check and document Q [every] shift as ordered. During an observation and interview on 4/30/24 at 9:31 A.M., the surveyor observed Resident #272 lying in bed with head of bed elevated and several respiratory equipment at his/her bedside, including a suction machine, an aerosol compressor, and an oxygen concentrator. Resident #272 said that he/she was actively being treated for throat cancer and recently had the Tracheostomy placed during his/her recent hospitalization. Resident #272 said that he/she uses the aerosol compressor which hooks up to the oxygen at night that is directly connected to his/her tracheostomy tube. During an observation and interview on 5/1/24 at 8:41 A.M., the surveyor observed the oxygen tubing and blue corrugated aerosol tubing was undated and hanging on the right bed rail. An aerosol drainage bag attached halfway along the blue corrugated tubing was observed to be placed directly on the floor. The surveyor also observed that the water container in the aerosol compressor machine was empty. During an interview at the time, Resident #272 said that the aerosol compressor had run out of water last night and he/she had turned the machine off. The surveyor observed two gallon containers of distilled water located in the room and the Resident said the distilled water were for the aerosol compressor use. The surveyor further observed the oxygen concentrator was set at 5 liters per minute (LPM - flow rate of oxygen) but was not currently in use by the Resident. The Resident said the oxygen concentrator and aerosol compressor are only used at night. During an interview on 5/1/24 at 3:11 P.M., Nurse #4 said that the aerosol compressor used by Resident #272 came with instructions on the settings for use and that it is only used at night for the Resident. Nurse #4 said the orders for the aerosol compressor settings was obtained from hospital paperwork. Nurse #4 demonstrated to the surveyor where the max fill line on the aerosol water container should be and said that the max fill amount typically lasts through the night. Nurse #4 further demonstrated the settings for the aerosol compressor to be set at 30 percent (%) and said the oxygen flow rate is usually set between 2 and 3 LPM. During an observation on 5/2/24 at 7:20 A.M., the surveyor observed Resident #272 lying in bed sleeping with the tracheostomy mask in place over his/her tracheostomy tube. The surveyor also observed that the oxygen concentrator with the aerosol corrugated tubing attached to the trach mask were in use. The surveyor further observed the aerosol compressor was set at 30% and the oxygen concentrator was set and running at 5 LPM. During an observation and interview on 5/2/24 at 1:05 P.M., the surveyor and the Director of Nurses (DON) observed Resident #272 lying in bed. The surveyor observed that the oxygen tubing, trach mask and blue corrugated aerosol tubing were all laying on the floor. The DON said that all the tubings and the trach mask should be stored in a bag and off of the floor and this would be immediately addressed for the Resident. During a follow-up interview on 5/2/24 at 3:27 P.M., the DON said that Resident #272 should have Physician orders in place to reflect the 5 LPM of oxygen in use with the aerosol compressor and orders to address the oxygen tubing changes. The DON further said these orders should have been in place but were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy and record review, the facility failed to provide services consistent with professional stands of practice related to hemodialysis (a procedure to remove waste products and fluid from the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for one Resident (#17), out of a total sample of 18 residents. Specifically, the facility failed to monitor Resident #17's AV (Arterio-Venous) Fistula (dialysis access site) for signs and symptoms of patency and infection. Findings include: Review of the facility policy titled Care of a Resident with End Stage Renal Disease (ESRD, the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), revised September 2010, indicated the following: -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -Education and training of staff includes, specifically: a. The nature and clinical management of of ESRD (including infection prevention and nutritional needs); b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; c. Signs and symptoms of worsening conditions; d. How to recognize and intervene in medical emergencies such as hemorrhages or septic infections; e. How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility); f. The care of grafts and fistulas; and g. The handling of waste -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the policy titled Hemodialysis Access Care, revised September 2010, indicated the following: -Care of AVFs (Arterio-Venous Fistula) . 1. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 2. To prevent infection/clotting: a. Keep the access site clean at all times b. Do not use the access site arm to take blood samples, administer IV fluids or give injections. c. Check for signs of infection (warmth, redness, tenderness or edema [swelling]) at the access site when performing routine care and at regular intervals. d. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals e. Check the patency of the site at regular intervals. Palpate (examination by touch) the site to the thrill or use a stethoscope (sic) to the whoosh or bruit of blood flow through the access (bruit - audible sound determined via stethoscope/ thrill - vibration that is felt when palpating the skin over an AV [arteriovenous - surgical connection between an artery and vein] fistula). -Documentation: The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observation post-dialysis. Resident #17 was admitted to the facility in September 2023, with diagnoses including End Stage Renal Disease (ESRD - a condition where the kidneys have reached an advanced state of loss of function) and received his/her Hemodialysis treatments three days a week via an AVF. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of total possible 15. Review of the Hemodialysis Plan of Care, last revised 1/10/24, indicated the following: -The Resident has a new fistula on his/her right lower extremity. -The goal is to have no signs or symptoms of complications from dialysis through the next review date. -Interventions include: >Monitor/document for peripheral edema. >Monitor/document/report to MD PRN (as needed) for signs or symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. >Monitor/document/report to MD PRN (as needed) for signs/symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock. Review of Resident #17's Order Summary Report dated 5/2/24, indicated the following: -Dialysis treatment received on Tuesday, Thursday, Saturday. Pick up time: 5:30 A.M., start date 10/7/23 -Dry Dialysis weights only *DO NOT WEIGHT IN HOUSE* Enter dry Dialysis Weight upon return every day shift every Tues, Thu, Sat, start date 9/28/23 -Hemodialysis General Care Orders: Center Nursing Staff may NOT perform any of the following procedures on external hemodialysis catheters: Infuse medications/ solutions; Flush catheter; change end caps; remove or repair catheter; obtain blood specimens; Change dressing. start date 9/12/23 -Monitor for pain every shift, start date 9/12/23 Review of the April 2024 and May 2024 Physician's Orders did not indicate that nursing interventions for monitoring for signs and symptoms of patency and infection at the fistula site were in place. Review of the Facility Progress Note dated 4/2/24, indicated the Resident: -returned from Dialysis and was unable to be dialyzed due to arm swelling -the swelling increased and was down to wrist in the right arm -requested to go to the Emergency Department (ED) for evaluation -the Nurse Practitioner (NP) was in agreement with the plan Review of the NP Progress Note on 4/2/24, indicated the following: -Resident #17 was evaluated for concern of right arm swelling and significant brushing [SIC]. -The Resident noticed increased swelling last night, he/she went to dialysis and was sent back as they were unable to perform dialysis. -Diagnosis of pain in right arm with unknown etiology (origin). -Questioning complication of fistula. -Significant bruising, pain, and swelling with restricted range of motion to the RUE (right upper extremity). -Resident requested to be evaluated at the ED. -Resident will need higher level of care for assessment as he/she missed dialysis as well as fistulogram (a special x-ray procedure that identifies abnormalities in the blood flow through the dialysis access site). During an interview on 4/30/24 at 11:20 A.M., Resident #17 said that he/she had recent issues with bruising and swelling to his/her arm with the fistula. Resident #17 said he/she was sent to the ED from the facility when he/she could not receive scheduled dialysis treatment. Resident #17 further said that he/she was hospitalized 4-5 days and required surgery to his/her right arm. During an interview on 5/1/24 at 3:01 P.M., Nurse #3 said she recalled Resident #17 returning from dialysis on 4/2/24 and noted significant bruising to his/her arm. Nurse #3 said the Resident told her that the issue occurred at dialysis, that the dialysis staff had difficulty accessing the fistula, and the Resident returned to the nursing facility. Nurse #3 said that sometimes the fistula site for the Resident is bruised when the Resident returns from dialysis. Nurse #3 further said that nursing staff check the fistula daily, review the dressing, monitor for bleeding, and note if there is bruit and thrill. During an interview on 5/2/24 at 2:15 P.M., the Director of Nurses (DON) said that the Physician's orders were updated to include checking access and monitoring the fistula for signs and symptoms of infection. The DON said that the orders for monitoring should have been initiated when the fistula was placed, but had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medications were stored safely and remained inaccessible to one Resident (#14) out of a total of 18 sampled residents. Specifically, the facility failed to: -ensure that [NAME] Lotion (an anti-itch topical [applied to the skin] medication) was safely stored, and locked up out of reach for Resident #14, resulting in him/her ingesting the medication and requiring hospitalization. -ensure that house barrier cream (a skin protectant cream) was safely stored and not easily accessible to Resident #14, resulting in him/her ingesting the medication and requiring monitoring for possible gastrointestinal upset. Findings include: Review of the facility policy titled Medication Storage in the Facility, revised 2019, indicated the following: -Medications and biologicals are stored safely, securely, and properly . -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Resident #14 was admitted to the facility in June 2019, with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of the Nursing Progress Note dated 11/10/23, indicated Resident #14 was found to be ingesting (swallowing) [NAME] Lotion, ingested six to eight ounces, and was subsequently sent to the hospital emergency room for evaluation. Review of the Root Cause Analysis (RCA) provided by the facility, dated 11/10/23, indicated the [NAME] Lotion had been placed on the nurse's station desk, not locked up, and was left unattended. The Resident was observed ingesting the lotion from the bottle. No additional documentation was provided to the surveyor regarding what interventions were put into place, or what education was provided to staff following the incident to reduce the likelihood that a similar incident would occur. Review of the Nursing Progress Note dated 3/30/24, indicated Resident #14 had ingested a calamine (anti-itch topical medication), hydrocortisone (an anti-itch topical mediation) zinc paste (a skin protectant topical medication) mixture (the facility's house barrier cream) and needed to be monitored for possible gastrointestinal upset. Review of the RCA provided by the facility dated 4/1/24, indicated the Resident was being provided care and the cup containing the house barrier cream was within reach of the Resident. The RCA further indicated that the Resident was able to stick his/her fingers in the house barrier cream, and placed his/her fingers in his/her mouth ingesting the cream. The RCA indicated an order was given by the Nurse Practitioner (NP) to monitor for gastrointestinal upset. No additional documentation was provided to the surveyor regarding what interventions were put into place, or what education was provided to staff following the second incident to reduce the likelihood that a similar incident would occur. During an interview on 5/1/24 at 1:02 P.M., the Director of Nurses (DON) said staff education was not completed following the two incidents of Resident #14 ingesting non-food items. During a follow-up interview on 5/1/24 at 2:56 P.M., the DON said nursing staff should not leave any medication unattended at the nurse's station or within reach of a resident. The DON again stated to the surveyor that she was unable to provide any documentation that education regarding proper storage of medication was completed with staff following the two incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one Resident (#14) out of 18 residents sampled. Specifically, for Resident #14, the facility staff failed to accurately update the Resident's Physician's orders to accurately match the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST- form that indicates a person's medical wishes regarding life sustaining treatments). Findings include: Resident #14 was admitted to the facility in [DATE], with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of the Resident's MOLST signed by the Resident Representative on [DATE], and by the Physician, Nurse Practitioner, or Physician's Assistant on [DATE], indicated the following request: -Do Not Resuscitate (do not perform cardiopulmonary resuscitation [CPR]-chest compressions) Review of the [DATE] Physician's orders indicated the following order: -Full Code (indicating the Resident wanted all life-sustaining treatment, including CPR) with an order date of [DATE]. During an interview on [DATE] at 9:42 A.M., Nurse #1 said if Resident #14 was to go into cardiac distress she would look in the electronic medical record (EMR) to see if the Resident had an order in place that he/she was a DNR or if he/she was a Full Code. The surveyor and Nurse #1 reviewed the Physician's orders and Nurse #1 said the Physician's orders said the Resident was a Full Code. Nurse #1 said she was not sure if the Physician's orders were accurate, and the surveyor and Nurse #1 next reviewed the Resident's MOLST. Nurse #1 said the MOLST indicated the Resident is a DNR and chest compressions should not be started if the Resident was in cardiac distress. Nurse #1 further said the Physician's orders and the MOLST should match and when the MOLST was completed, it did not appear that the Physician's orders had been updated to match.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards for one Resident (#272) out of a total sample of 18 residents, putting the Resident at risk for contamination and the spread of infection. Specifically, the facility staff failed to: -identify the need for Enhanced Barrier Precautions (EBP) for Resident #272, when the Resident was indicated with indwelling medical devices of tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and gastrostomy tube (G -Tube: a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication). -provide appropriate signage and communication to staff relative to EBP and the appropriate PPE (personal protective equipment) usage. Findings include: Review of the Centers for Medicare and Medicaid Memo QSO-24-08-NH, dated 3/20/24, indicated the following: -Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities. -EBP are used in conjunction with standard precautions and expand the use of Person Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing -EBP is indicated for nursing home residents with .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. -EBP should be used for any residents who meet the above criteria. -For residents whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, Tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. Resident #272 was admitted to the facility in April 2024, with diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Malignant Neoplasm of Larynx (cancer of the vocal chords), Chronic Obstructive Pulmonary Disease (COPD - chronic lung disorders resulting in blocked air flow in the lungs and breathing problems) and required the use of a Tracheostomy and enteral feeding via a G-tube (gastrostomy tube: a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication). During an observation on 4/30/24 at 9:57 A.M., the surveyor observed Rehabilitation (Rehab) Staff #1 assisting Resident #272 to ambulate towards the bathroom and proceeded to assist him/her into the bathroom. The surveyor observed that Rehab Staff #1 was wearing only a mask and gloves, and was not wearing a gown. The surveyor did not observe any signage within or outside the Resident's room indicating Enhanced Barrier Precautions (EBP). During an interview on 4/30/24 at 10:07 A.M., Rehab Staff #1 said that she should wear a mask and gloves when assisting Resident #272 in the bathroom. Rehab Staff #1 said that she would know if a resident was on Enhanced Barrier Precautions if there was signage outside of the Resident's Room and there would also be a Physician's order in the medical record indicating any Precautions. Rehab Staff #1 also said that she would ask the Nurse before entering a room with EBP signage to determine which resident had the EBP Precautions in place. During an interview on 5/2/24 at 10:20 A.M., the Assistant Director of Nursing (ADON) said that residents who needed to be on EBP would include those with G-tubes and tracheostomies. The ADON said the need for precautions would be communicated to staff via EBP signage outside of the residents' room and that facility staff have been educated on the proper use of PPE for EBP. During an observation and interview on 5/2/24 at 1:05 P.M., the surveyor and the Director of Nurses (DON) observed no signage indicating EBP was present for Resident #272's room. The DON said that anyone with wounds or openings such as feeding tubes or tracheostomies should be on EBP. The DON said the EBP signage indicates which PPE staff are to use when providing high-contact care for residents. The DON said there should be EBP signage outside of Resident #272's room and there was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #3 was admitted to the facility in September 2018 with diagnoses of Chronic Respiratory Failure (CRF - long term condition in which airways are damaged limiting movement of air through the body), Chronic Obstructive Pulmonary Disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and restricted air flow), and Unspecified Dementia (symptoms of cognitive dysfunction do not meet the criteria for a specific type of Dementia). Review of the Resident's clinical records indicated that Minimum Data Set (MDS) assessments were completed on 12/12/23 and 3/12/24. Review of the MDS assessment dated [DATE], indicated that the Resident had a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15, indicating Resident #3 was moderately cognitively impaired. During an interview on 4/30/24 at 8:42 A.M., the Resident said he/she did not know they had care plans. Review of the Resident's clinical record did not provide evidence of care plan meetings being held from December 2023 through April 2024, nor evidence the Resident or their representative had participated in the care planning process after the MDS assessments completed on 12/12/23 and 3/12/24. During an interview on 5/1/24 at 4:28 P.M., the Administrator said he could not provide evidence of care plan meetings being held since December 2023 for Resident #3, after MDS assessments were completed on 12/12/23 and 3/12/24. 4. Resident #60 was admitted to the facility in May 2023 with diagnoses including history of Stroke (damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area of the brain) and Hemiplegia (weakness or paralysis of one side of the body). During an interview on 4/20/24 at 9:54 A.M., Resident #60 said that he/she had a desire to discharge and return to the community but he/she had not had any care plan meetings to discuss discharge planning. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #60 had mild cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15. Review of the MDS assessment calendar indicated that comprehensive assessments were completed on the following dates: -5/9/23 -8/8/23 -11/7/23 -2/6/24 Further review of Resident #60's medical record did not provide evidence that the participation of Resident #60 in developing his/her plan of care was determined not to be practicable. During an interview on 5/1/24 at 4:27 P.M., the Administrator provided documentation of two care plan meetings held on 11/22/23 and 2/22/24. The Administrator said there was no evidence of care plan meetings held relative to the 5/9/23 and 8/8/23 comprehensive assessments. Review of the Care Plan Meeting Summary dated 11/22/23, indicated that the meeting included the Social Worker (SW), the Director of Nursing (DON), Resident #60's Representative, and the Representative's spouse. The meeting summary did not indicate that the Resident was invited to participate in the care plan meeting and declined, or that Resident #60 was included in the care planning process. Review of the Care Plan Meeting Summary dated 2/22/24, indicated the meeting included the SW, the DON, Resident #60's Representative, and the Representative's spouse. The meeting summary note did not indicate that the Resident was invited to participate in the care plan meeting and declined, or that Resident #60 was included in the care planning process. Based on record review and interview, the facility failed to conduct interdisciplinary care plan meetings after Minimum Data Set (MDS) assessments were completed, and also failed to involve the Resident and/or Resident Representative in the care planning process for four Residents (#2, #67, #3, and #60) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #2, provide evidence that the Resident and/or their invoked HCP had participated in the care planning process and that Interdisciplinary Team (IDT) care plan meetings were held for the Resident in 2024 following the MDS assessments completed on 1/9/24 and 4/9/24. 2. For Resident #67, provide evidence that the Resident and/or the Resident's Representative participated in the care planning process, or that a care plan meeting was held with the IDT following the MDS assessment completed on 1/24/24. 3. For Resident #3, provide evidence of care plan meetings being held, or that the Resident and/or Representative had participated in the care planning process following the MDS assessments completed on 12/12/23 and 3/12/24. 4. For Resident #60, provide evidence of two care plan meetings held after MDS assessments were completed on 5/9/23 and 8/8/23 and that the Resident was included in the care planning process for two care plan meetings held on 11/22/23 and 2/22/24. Findings include: Review of the facility policy titled Care Planning - Interdisciplinary Team, dated 2001 and revised September 2013, included: -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. -Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated 2001 and revised December 2016, included: -The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The IDT includes the resident and the resident's legal representative (to the extent practicable) -Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: participate in the planning process; . participate in establishing the expected goals and outcomes of care; . -The care planning process will: facilitate resident and/or representative involvement; . -An explanation will be included in the resident's medical record if the participation of the resident and his/her resident's representative for developing the resident's care plan is determined not to be practicable. -The comprehensive care plan is developed within 7 days of the completion of the required comprehensive assessment (MDS). 1. Resident #2 was admitted to the facility in March 2019 with diagnoses including Anxiety Disorder, Unspecified (feeling of unease, such as worry or fear, that can be mild or severe/intense, excessive, and persistent worry and fear about everyday situations), Schizophrenia Unspecified (a mental disorder characterized by recurring episodes of psychosis that are correlated with a general misperception of reality), and Major Depressive Disorder, Recurrent, Unspecified ( a mental disorder characterized by a pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Review of the Resident's Health Care Proxy (HCP - an appointed person to make health care decisions on your behalf if you are unable to make or communicate those decisions) indicated that the Resident had signed the form on 3/14/19 designating a HCP to make decisions for them. Review of the Resident's clinical record included a Documentation of Resident Incapacity, signed by the Physician on 3/20/19, indicating that the Resident lacked the capacity to make decisions and activating (invoking) the HCP for lifetime due to moderate cognitive impairment. Review of the Resident's clinical record indicated that MDS assessments had been completed on 1/9/24 and 4/9/24. Review of the MDS dated [DATE] indicated the Resident had moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15. During an interview on 4/30/24 at 10:32 A.M., the Resident said that they were not sure they had ever been to a care plan meeting. Review of the Resident's clinical record did not provide any evidence of care plan meetings being held from January 2024 through April 2024, nor evidence that the Resident or their invoked HCP had participated in the care planning process. During an interview on 5/1/24 at 10:08 A.M., Social Worker (SW) #1 said that she sends the invitations to the care plan meetings out at least a month in advance. SW #1 said that she invites residents and responsible parties, and even if the HCP is invoked, she still invites the residents. SW #1 said that she uses a care plan attendance document. SW #1 said the documents are not kept in the resident records, and that all care plan meeting invitations and attendance records are kept in a binder in the SW's office. When the surveyor asked SW #1 to provide the care plan attendance sheets for Resident #2 relative to the MDS assessments completed on 1/9/24 and 4/9/24, SW #1 was unable to provide evidence that the Resident or the Resident's Representative participated in the care planning process following the MDS completion on 1/9/24 and 4/9/24. SW #1 was also unable to provide evidence that a care plan meeting was held with the IDT following the MDS assessments completed on 1/9/24 and 4/9/24. During an interview on 5/1/24 at 4:27 P.M., the Administrator said that he was unable to provide evidence that any Interdisciplinary Team (IDT) care plan meetings were held for Resident #2 in 2024. 2. Resident #67 was admitted to the facility in January 2024, with diagnoses including Type II Diabetes (DM II - condition in which the body does not produce enough insulin and had trouble controlling blood sugar levels) and Acquired Absence of Right Leg Below Knee (Amputation of the right leg below the knee). Review of the Resident's clinical record indicated that a Minimum Data Set (MDS) assessment had been completed on 1/24/24. Review of the MDS assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15. During an interview on 4/30/24 at 8:59 A.M., the Resident said that he/she did not recall ever being invited to, or participating in a care plan meeting. Review of the Resident's clinical record did not provide evidence of care plan meetings being held from January 2024 through April 2024, nor evidence that the Resident or their Representative had participated in the care planning process after the MDS assessment completed on 1/24/24. During an interview on 5/1/24 at 10:08 A.M., the surveyor asked SW #1 to provide the care plan attendance sheet for Resident #67 relative to the MDS assessment completed on 1/24/24. SW #1 was unable to provide evidence that the Resident or the Resident's Representative participated in the care planning process following the MDS completion on 1/24/24. SW #1 was also unable to provide evidence that a care plan meeting was held with the IDT following the MDS completed on 1/24/24. During an interview on 5/1/24 at 4:27 P.M., the Administrator said that he was unable to provide evidence that an Interdisciplinary Team (IDT) care plan meeting was held for Resident #67 in 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to: 1) conduct surveillance for COVID-19 symptoms during a COVID-19 outbreak for 3 Residents (#1, #4, and #6) out of a total of 3 Residents sampled, and 2) ensure that its staff adhered to the Department of Public Health (DPH) guidelines and the facility policies pertaining to the use of Personal Protective Equipment (PPE) to prevent the spread of infection. Specifically, 1) the facility staff failed to conduct surveillance of COVID-19 symptoms for each Resident during outbreak testing on each shift as required, and 2) failed to don (put on) face mask while in a resident care area, and also failed to don the required PPE when entering a resident room designated as Quarantine Precautions. Review of the DPH Memorandum titled: Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/2022 indicated: -On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID-19 during each shift. -Full PPE, including N95 respirator or alternative, eye protection, gloves, and gown, should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19. -Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with residents and in alignment with DPH and CDC guidance. -All long-term care facility personnel should wear a face mask while they are in the facility Review of the Quarantine Precaution sign posted outside of resident room doorways included that everyone must: -wear eye protection -gown and glove Review of facility Policy titled COVID-19 dated 3/27/20, indicated: -In addition to Standard Precautions, Contact and Droplet Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. Follow local public health and state regulations when applicable. -implement universal use of face masks and other PPE as needed in patient care areas while in the Center. -monitor all patients each shift for fever, cough, body aches, malaise and signs/symptoms of respiratory infection including abnormal heart rate or pulse oximetry. -Follow the State Board of Health, as well as CDC Interim Infection Prevention and Control Recommendations for suspected COVID-19 in healthcare setting for suspected patient or employee with COVID-19. 1) The facility failed to conduct surveillance for COVID-19 symptoms during a COVID-19 outbreak for 3 Residents (#1, #4 and #6). Findings include: a. Resident #1 was admitted to the facility March 2017. Review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 11/5/22 -11/17/22 did not show any evidence of surveillance for COVID-19 symptoms for any shifts during the review period. b. Resident #4 was admitted to the facility in April 2022. Review of Resident #4's MAR and TAR from 11/5/22-11/17/22 did not show any evidence of surveillance for COVID-19 symptoms for any shifts. c. Resident #6 was admitted to the facility in October 2016. Review of Resident #6's MAR and TAR from 11/5/22-11/17/22 did not show any evidence of surveillance for COVID-19 symptoms for any shifts. During an interview on 11/17/22 at 3:04 P.M., the Minimum Data Set (MDS) Nurse said that residents should be monitored each shift for signs and symptoms of COVID-19 during an outbreak and it should be documented in the medical record using the MAR or TAR. During an interview on 11/17/22 at 3:45 P.M., Nurse #3 said that the entire building was currently conducting outbreak testing which began on 11/5/22. Nurse #3 further said that all residents should be screened each shift for signs and symptoms of COVID-19 whenever outbreak testing is being conducted. Nurse #3 said that the information should be documented in the resident's clinical record on the MAR and/or TAR. Nurse #3 was unable to provide any evidence that Residents #1, #4 and #6 were screened for signs and symptoms of COVID-19 each shift as required. 2) The facility staff failed to don face masks while in a resident care area, and also don the required Personal Protective Equipment (PPE) when entering a resident room designated as under Quarantine Precautions. On 11/17/22 at 2:20 P.M., the surveyor observed CNA #2 walk down the facility hallway just outside of resident room [ROOM NUMBER] with her mask folded under her chin, with no face covering over her nose or mouth. She then entered room [ROOM NUMBER] and stood just inside the doorway speaking with the Resident. CNA #2 was approximately 2 feet from the Resident during the conversation. She then exited room [ROOM NUMBER], re-entered the hallway and walked down the hall past the nursing station with her mask still below her chin. During an interview on 11/17/22 at 2:25 P.M., CNA #2 told the surveyor that she felt it was alright to take off her mask while speaking with the resident in room [ROOM NUMBER] because she did not think the resident had COVID, so she wouldn't catch COVID from them. CNA #2 then said that she actually realized that she was supposed to wear her mask at all times in the facility, and so she should not have put her mask down below her chin. On 11/17/22 at 2:30 P.M., the surveyor observed CNA #2 enter room [ROOM NUMBER]. room [ROOM NUMBER] had a Quarantine Sign posted outside the door and a tote with PPE supplies in the hallway just outside the doorway. CNA #2 did not perform hand hygiene, apply eye protection, apply a gown, or don gloves before entering the room. Once in the room CNA #2 interacted with one resident and then crossed the room and interacted with a second resident. During an interview on 11/17/22 at 2:35 P.M., CNA #2 told the surveyor that she thought it was alright to go into room [ROOM NUMBER] without wearing the PPE listed on the Quarantine Precaution sign because she was just going in the room to quickly to talk to the residents. CNA #2 then said she probably should have put on the PPE listed on the sign. During an interview on 11/17/22 at 2:36 P.M., Nurse #1 told the surveyor that the expectation was that all staff would wear their face masks at all times. She further said that all staff entering a resident room that had a Quarantine Precaution sign outside the door were expected to perform hand hygiene, and don an N95 mask, gown, eye protection, and gloves. Furthermore she said that they should only interact with one resident at a time, then exit the room, and repeat the steps for hand washing and PPE use to interact with another resident in the same room.

Based on record review, and interview, the facility failed to ensure that its staff conducted Covid-19 testing for all residents as required, following an identified outbreak of Covid-19 infections. Specifically, the facility staff failed to: 1) conduct outbreak testing of all residents to ensure new Covid-19 cases were identified, and 2) document dates and results of Covid-19 testing of all residents. Findings include: Review of the facility policy titled, Coronavirus Testing, dated May 17, 2020, indicated the following: Upon identification of a new COVID-19 case in the facility (i.e. outbreak), document: -Date the case was identified -Date other staff and residents are tested -Dates the staff and residents who tested negative are retested -Results of all tests Review of the facility policy titled Coronavirus Disease (COVID-19) - Testing Residents dated, August 2020, included: -Viral testing of all residents is conducted if there is an outbreak in the facility. -an outbreak is defined as any single new onset of SARS-CoV-2 infection in a resident or a single case of infection in healthcare personnel. -Viral testing of all previously negative residents is repeated every 3 to 7 days until testing identifies no new cases of SARS-Co-V-2 infection among residents or healthcare personnel for at least 14 days since the most recent positive result. Review of the Department of Public Health (DPH) Memorandum titled: Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 10/13/2022 indicated: -On unit(s) conducting outbreak testing, a long-term care facility should assess residents for symptoms of COVID-19 during each shift. -Residents who are a close contact of a case of COVID-19 and are not recovered from COVID-19 in the last 30 days should be tested as soon as possible, but not sooner than 24 hours following exposure, on Day 3 and Day 5, and should wear a mask around others through Day 10. Review of a facility email from Additional Staff #1, addressed to responsible parties at the facility dated 11/5/22 at 4:31 P.M., indicated that a staff member had tested positive for Covid-19. During an interview on 11/17/22 at 7:36 A.M., Additional Staff #2 told the surveyor that on 11/5/22 the first Covid-19 positive staff was identified, and facility wide outbreak testing was initiated. Additional Staff #2 further said that there were subsequently additional residents and staff tested positive for Covid-19 and the facility has been conducting outbreak testing continually since 11/5/22. Review of the Covid-19 outbreak testing documents provided, did not indicate any evidence that the facility conducted outbreak testing for all residents as required, in response to the identification of Covid-19 positive staff member on 11/5/22. During an interview on 11/17/22 at 3:43 P.M., Nurse #3 said that the Covid-19 outbreak started on 11/5/22. She further said that all of the residents were tested for Covid-19 every 48 hours since the start of the outbreak. Nurse #3 was unable to provide any evidence of the 48-hour Covid-19 testing conducted for the residents. Nurse #3 said they only documented positive cases and kept no record of any negative Covid-19 results. Nurse #3 was unable to provide any evidence of when the last residents were tested for Covid-19 or the results of those tests.

Based on observation, record review, and interviews, the facility failed to ensure that its staff provided Podiatry care for one Resident (#20) out of 15 sampled residents. Specifically, lack of appropriate foot care leading to poor foot health and the development of a pressure ulcer on the Resident's left index toe. Findings include: Resident #20 admitted to the facility in August 2022 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Hypertension (high blood pressure). Review of Resident #20's Minimum Data Set (MDS) Assessment, dated 8/18/22, indicated that the Resident was cognitively impaired as evidenced by completion of the staff assessment indicating both impaired short-term and long-term memory, as well as impaired decision makings skills. Further review of the MDS revealed that the Resident required extensive assistance for personal hygiene and was at risk for the development of pressure ulcers. Review of Resident #20's Activities of Daily Living (ADL) care plan, last revised 8/25/22, indicated that he/she required total assistance with personal hygiene care. Review of Resident #20's Skin Observation Tool dated 10/24/22 indicated that the Resident's great mycotic (fungal infection) toenail is rubbing/pressing against the right second toe inner aspect creating a 1.5 centimeter (cm) by 1.5cm sore with surrounding redness. Review of the Physician's progress note, dated 10/24/22, indicated that the Resident had an open area on the second toe that was caused by area rubbing against the second toe from the great toe. Review of the Physician's progress note, dated 10/25/22, indicated that the Resident was diagnosed with a right second toe pressure ulcer (erroneous wound site (right toe) documentation by writer). On 10/26/22 at 10:24 A.M., the surveyor observed Resident #20's feet. The toenail of the big toe on the Resident's left foot appeared thick, yellow/brown in color and overgrown in length. The left index toe had a dressing with some drainage on it. During an interview on 10/27/22 at 11:16 A.M., Nurse #1 said that Resident #20's wound was caused by the elongated fungal toenail rubbing up against the second toe. Review of the resident record did not indicate that Resident #20 had been seen by Podiatry, and also did not reveal a consent for Podiatry had been completed. During an interview on 10/27/22 at 11:48 A.M., the Administrator said that the consent form for Podiatry had not been completed upon admission, resulting in the Resident not being seen by Podiatry to have his/her nails trimmed.

Based on interview, the facility failed to ensure that all Certified Nurses Aides (CNA) were offered the 12 hours of in-service education training as required annually. Findings include: During an interview on 10/28/22 at 8:57 A.M., the Director of Nurses (DON) said that she and the new Staff Development Coordinator (SDC) were working on staff training. She said she was unsure if the facility had provided 12 hours of in-service education to the CNAs. During an interview on 10/28/22 at 2:05 P.M., the SDC said the facility provided an educational competency fair for the staff. The SDC said she was unsure if the facility had provided 12 hours of education for all CNAs. During an interview on 10/31/22 at 12:17 P.M., the DON said she was unable to provide evidence that 12 hours of training was provided by the facility to the CNA's as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure its staff provided care and services related to Substance Use Disorder (SUD- a mental disorder that affects a person's brain and behavior, leading to a person's inability to control their use of substances such as legal or illegal drugs, alcohol, or medications. Symptoms can range from moderate to severe, with addiction being the most severe form of SUDs) for one Resident (#18) out of 15 sampled residents. Findings include: Resident #18 was admitted to the facility in [DATE]. Review of the Health Care Facility Reporting System (HCFRS) indicated the facility reported that Resident #18 sustained a drug overdose in the facility on [DATE]. Review of a Progress Note, dated [DATE], indicated the Resident returned to the facility from the hospital. Further review of the Progress Note, dated [DATE], indicated the Resident had an unresponsive episode at the facility on [DATE] and Emergency Medical Technician's (EMTs) administered Narcan (medication used to reverse an opioid overdose) and the Resident became more responsive. The Resident was sent to the hospital for an evaluation. The toxicology screen done in the hospital was positive for Fentanyl (not administered or ordered by the facility) and opioids (Resident admitted to ingesting heroin). The Resident revealed he/she had been a heroin addict and had been in recovery but just wanted a break and made the decision to obtain and ingest the drugs (provided by a visitor). The nurse discussed support services including available online options for substance abuse/recovery and the Resident responded maybe to these services. Review of the care plan, indicated a new focus was added on [DATE] that included the Resident had acknowledged contacting a drug dealer to provide him/her with drugs and acknowledged he/she almost died from an overdose and was still seeking Oxycodone from the Nurses and Physician at the facility. -The goal, dated [DATE], was for the Resident to not have contact with alleged drug dealers or take illegal drugs and to keep facility and self safe. -Review of the interventions indicated to offer substance abuse treatment clinics as options for care. -No new interventions had been added since [DATE], immediately following the overdose. Review of the Resident's list of diagnoses did not include a history of SUD (after the Resident admitted to using heroin in the past and sustaining an overdose in the facility). Review of the Physician/Nurse Practitioner (NP) visits in the clinical record, did not indicate any reference to SUD or providing/offering services or rehabilitation options for drug addiction recovery. Review of clinical record indicated the Resident had been followed by behavioral health services in the facility. Review of the behavioral health service visits, dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] indicated, under the section for substance abuse/addiction history that the Resident was a current smoker and denied alcohol abuse (records indicate alcohol abuse). The treatment plan included to monitor for any new or worsening mood, behaviors or psychotic features. The treatment plan did not include providing services or rehabilitation options for drug addiction recovery. On [DATE] at 1:39 P.M., the surveyor observed, with Nurse #4, a box of Narcan in the [NAME] Unit medication room. Nurse #4 said she had not been trained by the facility on how to administer it, but had received training elsewhere. During an interview on [DATE] at 2:18 P.M., the Staff Developer Coordinator (SDC) said they just got the Narcan in a week or two ago and they were putting paper inservice training information related to the use of Narcan on the nursing units, for the nurses to review. During an interview on [DATE] at 3:01 P.M., the Director of Nurses (DON) said she was not working in the facility in [DATE]. The surveyor and the DON reviewed the situation concerning the Resident having an overdose in the facility: -That a diagnosis of SUD was not added to the clinical record and there was no evidence that supportive services related to addiction recovery were offered since [DATE]. -There were no orders for Narcan and Narcan was not put into place when the Resident returned from the hospital, after the overdose. -The Narcan was not available in the facility until nearly seven months later. The DON said she understood the concerns and that normally they would monitor someone closely once they knew they had a history of SUD. She said she understood the concern that this information wasn't readily available in the record, or available for direct staff. When the surveyor requested the facility policy for care and services related to SUD, the DON provided the policy for administration of Narcan and said she did not have any other policies related to SUD.

Based on observation, record review, and interview, the facility failed to ensure its staff maintained a medication error rate less than 5%. Specifically, two out of three nurses observed failed to administer medications as ordered, for one Resident (#7). The medication error rate was calculated at 8% with 25 opportunities for error. Findings include: Resident #7 was admitted to the facility in June 2017 with a diagnosis of End Stage Renal Disease (ESRD- a disease that affects the kidneys and leads to loss of kidney function). During a medication administration observation on 10/27/22 at 7:44 A.M., the surveyor observed Nurse #1 pour and administer medications to Resident #7 including two 325 milligram (mg) tablets of Sodium Bicarbonate (given to people with ESRD to slow down the loss of kidney function) equaling a total dose of 650 mg of Sodium Bicarbonate. Review of the October 2022 Physician orders indicated an order initiated on 9/22/22, for Sodium Bicarbonate Tablet 650 mg, give 1300 mg by mouth in the morning related to acute kidney failure, unspecified. During an interview and medication review on 10/27/22 at 9:04 A.M., Nurse #1 said that she administered two 325 mg tablets of Sodium Bicarbonate equaling a total dose of 650 mg. She said the Resident should have gotten four 325 mg tablets to equal a total dose of 1300 mg as ordered. During a medication administration observation on 10/31/22 at 10:06 A.M., the surveyor observed Nurse #3 pour and administer medications to Resident #7 including one tablet of Vitamin D 10 micrograms(mcg) per 400 International Units (IU). Review of the October 2022 Physician orders indicated an order, initiated on 9/22/22, for Vitamin D3 1000 IU by mouth in the morning for supplement. During an interview and medication review on 10/31/22 at 10:50 A.M., Nurse #3 said she gave Vitamin D 10 mcg per 400 IU but that the Resident was supposed to receive Vitamin D3 1000 IU as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and test tray results the facility failed to ensure its staff provided palatable food to Residents on one sampled nursing unit. Findings include: The following comments regarding food palatability occurred on the [NAME] nursing unit: On 10/26/22 at 10:41 A.M., Resident #45 said: They think if they cover the food with gravy it makes it good. The food tastes bad and they don't cook it properly. The Resident said that he/she has to order shakes off of Amazon so he/she doesn't have to deal with the food. The Resident also said he/she has talked to managers and people in charge and they do nothing about the food. The surveyor observed an open can labeled Nutrament shake on the Resident's bedside table. On 10/26/22 at 11:30 A.M., Resident #54 said: The food is beyond horrible, it used to be at the low end of horrible but now it's at the high end of horrible. I have to ask for something different every day. On 10/27/22 at 12:19 P.M., on the [NAME] nursing unit the palatability results of a test tray were as follows: Turkey Meatloaf - had a strong bitter taste. Mashed Potato - had a strong bitter taste Bread Stuffing - faint bitter taste Wax Beans - faint bitter taste Ambrosia - no issues Coffee - no issues On 10/27/22 at 1:04 P.M., the Food Service Director was made aware of the food palatability concerns and the results of the test tray which validated resident concerns.

Based on document review and interview, the facility failed to ensure that its staff notified Residents, families, or Resident Representatives of COVID-19 positive staff cases in the facility by 5:00 P.M. the next calendar day during the month of October 2022, as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed or Suspected COVID-19 cases of Residents and staff in nursing homes, Reference: QSO-20-29-NH dated May 6, 2022, indicated: (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . During an interview on 10/26/22 at 11:02 A.M., the Infection Preventionist (IP) said that the last staff member in the facility to test positive for COVID occurred on 10/3/22. She also said that the Administrator was responsible for emailing families/representatives with COVID positive updates and that the previous IP employee had called families for notification as well. During an interview on 10/31/22 at 3:57 P.M., the Administrator said that they notify families/representatives of COVID positive infections on a case-by-case basis. He also said that he had not sent an email notifying families/representatives of COVID positive infections since May 2022. During an interview on 10/31/22 at 4:36 P.M., the Director of Nurses (DON) said that the resident, representatives, and families should have been notified of the COVID positive staff member (10/3/22) and they were not.

Based on record review, policy review and interview the facility failed to ensure that its staff maintained education regarding the potential benefits and risks of the COVID-19 vaccination for two Residents (#50 and #51) out of five sampled residents. Specifically, the facility failed to ensure that its staff provided evidence of offering the COVID-19 vaccination and that the Residents refused. Findings include: Review of the facility policy titled Infection Control-COVID VACCINATION, dated 5/15/21, indicated the resident's medical record includes documentation that indicates, at a minimum, the following: -that the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and -each dose of COVID-19 vaccine administered to the resident, or -if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. 1. Resident #50 was admitted to the facility in September 2022. Review of the medical record failed to indicate that the Resident had been offered and/or was educated on the COVID-19 vaccine. There was no declination form for the COVID-19 vaccine in the record. 2. Resident #51 was admitted to the facility in September 2022. Review of the medical record failed to indicate that the Resident has been offered and/or was educated on the COVID-19 vaccine. There was no declination form for the COVID-19 vaccine in the record. During an interview on 10/31/22 at 12:22 P.M., the Infection Preventionist (IP) said that the COVID declination consents should have been in the Resident's records, but they were not.

Based on document review, and interview, the facility failed to ensure its staff reviewed and updated the Facility Assessment yearly (missing two years), to determine what resources are necessary to competently care for its residents during both day-to-day operations and emergencies. Finding include: On 10/28/22 at 8:57 A.M., the surveyor reviewed the Facility Assessment document. It was signed and dated 8/27/20. During an interview on 10/28/22 at 12:33 P.M., the Director of Nurses(DON) said the current Facility Assessment had not been updated and/or reviewed since 8/27/20. During an interview on 10/28/22 at 12:41 P.M., the Administrator said, after reviewing the Facility Assessment, that it had not been updated and/or reviewed yearly, as required.